{include file="header.tpl" title=PSN-Clinic}

	<td>
	<h2>Search Patient</h2>
	<form action="patients.manage.php" method="get">
	<table height="30" border="0" cellpadding="5" cellspacing="0">
        <tr>
          <td height="19" class="mainText">
            <strong>Find:&nbsp;</strong><input type="text" name="q" value="{$q}">
			<td><button type="submit" style="width:80px;">OK</button></td>
        </tr>
      </table>
</form>
	<h2>Patient Information</h2>
			<div class="left" id="reg-page">
			
				<form method="post" action="patients.manage.php" class="form">
					<table width="400" border="0" cellspacing="10" cellpadding="5">
					<tr>
						<td><label for="reg-name">First Name</label></td>
						<td><input type="text" class="text" name="patientFName" id="patientFName" value="{$patients.patientFName}" /></td>
					</tr>
							<tr><td><label for="reg-name">Middle Name</label></td>
							<td><input type="text" class="text" name="patientMName" id="patientMName" value="{$patients.patientMName}" /></td></tr>
						
							<tr><td><label for="reg-name">Last Name</label></td>
							<td><input type="text" class="text" name="patientLName" id="patientLName" value="{$patients.patientLName}" /></td></tr>
						
						<tr><td><label for="reg-gender">Gender</label></td>
						
							<td><select name="patientGender" id="patientGender">
								<option value="0" > -- select -- </option>
								<option value="m" {if $patients.patientGender eq 'm' } selected="selected" {/if}>male</option>
								<option value="f" {if $patients.patientGender eq 'f' } selected="selected" {/if}>female</option>
							</select></td></tr>
						
							<tr><td><label for="reg-email">BirthDate</label></td>
							<td><input type="text" name="birthdate" id="birthdate" value="{$patients.birthDate}" /></td></tr>
						
							<tr><td><label for="reg-email">Email</label></td>
							<td><input type="text" class="text" name="Email" id="Email" value="{$patients.Email}"  /></td></tr>
						
							<tr><td><label for="reg-name">Landline </label></td>
							<td><input type="text" class="text" name="landline" id="landline" value="{$patients.landline}" /></td></tr>
						
							<tr><td><label for="reg-name">Mobile</label></td>
							<td><input type="text" class="text" name="mobile" id="mobile" value="{$patients.mobile}" /></td></tr>
						
							<tr><td><label for="reg-email">Address</label></td>
							<td><input type="text" class="text" name="address" id="address" value="{$patients.address}"  /></td></tr>
						
							<tr><td><label for="reg-email">Address</label></td>
							<td><input type="text" class="text" name="address1" id="address1" value="{$patients.address1}"  /></td></tr>
							<tr><td><label for="reg-email">City</label></td>
							<td><input type="text" class="text" name="city" id="city" value="{$patients.city}"  /></td></tr>
							<tr><td><label for="reg-email">PIN</label></td>
							<td><input type="text" class="text" name="pin" id="pin" value="{$patients.pin}"  /></td></tr>
							
							
													
							
						<tr><td><button type="submit" class="btn-big"><em>Add</em></button></td></tr>
						<input type="hidden" name="add" value="true" />
							
						</table>
				</form>
			</div>
	</td>
</tr>
</table>

{include file="footer.tpl"}